A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions

A 3-year-old child who has an atrial septal defect and a heart rate of 120/min

A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL

A 2-year-old child who has diarrhea and reports abdominal pain

Answer and Explanation

The Correct Answer is A

A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.

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Correct Answer is B

Explanation

A. Stating that the client received morphine "around lunch" is too vague. The exact time, dose, and effect should be included for accurate pain management.
B. A lung biopsy is a significant procedure that requires close monitoring for complications such as pneumothorax or bleeding. The oncoming nurse must be aware to provide appropriate post-procedure care.
C. General information about vital signs being taken every 4 hours is routine and not critical for handoff unless there are abnormalities or changes.
D. The presence of the client’s partner is not essential clinical information unless it impacts care, such as decision-making or emotional support needs.

A. "How are things going at your job?" B. "Why do you think this is happening to you?" C. "You must he feeling very frightened right now." D. "Maybe you should think more positively."

Correct Answer is C

Explanation

A. "How are things going at your job?" This response redirects the conversation rather than addressing the client's emotional state.
B. "Why do you think this is happening to you?" This question may come across as challenging or blaming, which is not therapeutic.
C. "You must be feeling very frightened right now." This response validates the client's emotions, showing empathy and encouraging further expression of feelings.
D. "Maybe you should think more positively." This dismisses the client's distress and does not provide therapeutic support.

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A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A nurse is speaking with a client during a counseling session who states, "I feel like I am sliding off a cliff." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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